On February 10, 2026, the Department of Health Care Services (DHCS) Office of Family Planning published the updated version of the Site Certifier for Multiple Service Locations Declaration (DHCS 4475). This form is used to request DHCS approval for one site certifier to oversee up to 10 service locations for designated clinic types specified in the Provider Enrollment and Responsibilities section of the Policies, Procedures and Billing Instructions Manual.
What Has Changed:
- Each DHCS 4475 allows the site certifier to designate one additional service location – in addition to their main location – per form.
- Provider must submit a DHCS 4475 for each additional service location.
- Additional supporting documentation is now required with each submission.
- The form has been updated with new instructions explaining how to complete and submit the request for multiple locations (up to 10).
Providers planning to designate one certifier to oversee multiple service locations (up to 10) must:
- Complete the updated Family PACT Site Certifier for Multiple Sites Declaration.
- Submit to the completed form and required documentation to Providerservice@dhcs.ca.gov for review and approval.
The updated DHCS 4475 is available for download on the Family PACT website and the Medi-Cal Provider Forms web page.
Previous versions of the DHCS 4475 will no longer be accepted after March 1, 2026.